Evington Home - Pilgrims' Friend Society

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People’s safety was a priority at the service and concerns about safety were investigated and reported to the relevant authorities. The service had a learning culture, and the provider and registered manager made improvements following safety incidents.

For example, following an incident when a person may have been unsafe while out in the community, the registered manager introduced a new protocol for staff to follow. This ensured people had a risk assessment before they left the service so the person, and those accompanying them, were aware of any potential risks. This helped to ensure people were always safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Each person had a pre-admission assessment before coming to the service. The registered manager completed this in conjunction with the person and their relative/representative. Pre-admission assessments contained key information about the person including their health and social care needs and any areas they were at risk.

The pre-admission assessment was shared with staff during handover meetings and meant that when a person arrived staff understood their needs and how to keep them safe. This helped to ensure the person had a smooth transition into the service and received continuity of care. A staff member told us, “If a new person is coming to live here all staff are made aware of their needs.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and relatives said people were safe at the service. A person told us, “I feel safe here and everyone is good to me.” Staff were trained in safeguarding and knew what to do if they had concerns about the welfare of any of the people using the service. A relative told us they were ‘really pleased that [person] is in a safe place’. Another relative said their family member was ‘absolutely safe in every way’.

The provider had clear safeguarding systems, processes and practices to protect people from harm. Managers and staff took appropriate action if safeguarding incidents occurred. This included liaising with the local authority who takes the lead in safeguarding investigations. Staff understood their safeguarding responsibilities. A staff member said, “People are looked after and are safe. I would report to a manager if I was not happy with any situation [regarding people’s safety].”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had personalised risk assessments, so staff knew how to keep them safe. For example, a person’s falls risk assessment covered all aspects of their mobility including walking and transferring. Staff followed this to ensure the person could move safely using the appropriate aids and adaptations. If people needed extra staff support to maintain their safety, this was provided.

People and relatives, where appropriate, were involved in discussion about risks and their views listened to. Advice and instructions from health and social care professionals formed part of people’s risk assessments and reflected the service’s holistic approach. Risk assessments were regularly reviewed and updated as people’s needs changed.

The provider detected and controlled most risks in the care environment. They had processes in place to ensure equipment, facilities and technology supported the delivery of safe care. However, these were not always effective.

Most areas of the premises were safe and well-maintained. However, some sinks had exposed piping underneath them which were hot to the touch and could present a risk of scalding if a person fell against them. We brought this to the attention of registered manager and provider who immediately took action to address this risk, arranging for the piping to be boxed-in or otherwise made safe.

The safety of the premises was checked and managed by the provider’s maintenance team to support people to stay safe. Records showed audits took place to ensure the premises and equipment were safe and properly maintained.

The provider continually improved the premises to increase safety. For example, a new call bell system had been installed, the roof was being upgraded, and a first-floor bathroom refurbished. In addition, the provider had approved finance for laminate flooring to be fitted in corridors and communal areas throughout the premises, and in bedrooms where people said they would like this.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were sufficient staff on duty to meet people’s needs. People and relatives told us the service was well-staffed. A person told us, “There are always staff to help us, and they are all very kind.” Relatives said there were enough staff on duty when they visited, both during the week and at weekends. They told us staff regularly checked on their family members and were always present in the lounges.

In addition to the care staff, the provider employed staff known as ‘hummingbirds’ who interacted and engaged with people and supported them to take part in daily life at the service. The service also had over 30 volunteers who visited people to provide prayers, company and activities. The staffing arrangements meant that people received safe care and additional staff and volunteer support to enhance their well-being.

Staff had the right qualifications, skills, knowledge and experience to deliver safe and effective care. Relatives said staff were competent and provided good quality care and support. Comments included: ‘they know what they are doing’; ‘all my observations have been good’; and ‘they seem fine when they operate the hoist’.

Staff and volunteers were safely recruited by managers, in conjunction with the provider’s human resources department, to ensure they were fit to work with people using care services. Where possible, people were involved in the recruitment process, so they had a say in who was employed at the service.

The provider’s approach to assessing and managing the risk of infection was mostly effective and in line with current relevant national guidance.

Some minor upgrades were required to improve IPC (infection prevention and control) at the service. All toilet rolls needed to be in closed containers, and the threshold to the laundry, where bare wood was exposed, needed repairing. The registered manager said both these issues would be promptly addressed.

Relatives made many positive comments about premises which were visually clean and tidy throughout. These included: ‘very clean’; ‘[person’s] room is always clean’, and ‘cleaned to a high standard’. All the people using the service had been offered annual flu and COVID 19 vaccinations with the majority accepting these.

Staff had infection control training which was updated annually and included donning and doffing of personal protective equipment (PPE). Handwashing was observed during infection control audits and the registered manager’s weekly walk around. The service had a dedicated housekeeping team who had the resources they needed to keep the premises clean.

Managers and staff had the support of the provider’s IPC lead who was available to support the introduction of any new guidance regarding infection control. Managers carried out monthly IPC audits where they identified risk and took action to reduce this. The service was regularly inspected by the local authority’s IPC team, scoring 91% at the last inspection in February 2025.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

At the time of our inspection the service did not have a dedicated medicines room. Medicines were kept securely in different areas, each with their own temperature monitoring systems. This had proved a challenge in the summer when, on occasions, staff had had to use ice blocks to keep temperatures below the required maximum. The registered manager said the provider had given the go-ahead for a dedicated medicines room to be created to make it easier for staff to safely manage and store medicines.

People had personalised medicines care plans which explained how they liked to take their medicines, whether they wished to self-administer them, and how they let staff know if they required pain relief. Records showed people’s medicines were regularly reviewed by GPs and staff at the service. Relatives said people had their medicines on time and records confirmed this.

Medicines were administered by trained senior staff who had 6-monthly competency checks to ensure their skills remained up to date. All staff had basic medicines training. The service’s local pharmacy provided support and advice to staff on medicines management, storage and administration. The pharmacy conducted annual medicines audits to support the service.